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Coping with Chronic Pain

Do you remember the last time you felt pain? Perhaps you stubbed your toe on the corner of a door, hit your thumb with a hammer, or burned your finger by touching the top of a steaming pot of coffee.

As in these situations, most of the pain you suffer over the course of your life is intense but short-lived. This is called acute pain. Through your body's natural healing powers and, in some cases, medical treatment, your pain goes away.

But there is another form of pain that doesn't go away. This is called chronic pain. When it strikes, signals of pain keep firing within your nervous system for weeks, months or even years. In some cases, chronic pain stems from an injury that occurred years before. At other times, chronic pain appears in the absence of any past injury or bodily damage.

For many people, chronic pain is a daily torment. There are many types of chronic pain. Some of the most common causes are arthritis, back problems, cancer, headaches, facial pain, nerve damage, spinal cord injury and bums. Of all types of chronic pain, low back pain is the most common. And of all age groups, chronic pain most often affects middle-aged to senior adults.

Some experts say chronic pain is a very costly health problem. The impact of chronic pain, including direct medical expenses, lost income, lost productivity, compensation payments and legal charges, can run to billions of dollars annually. Aside from these staggering financial implications, the toll in human suffering is immeasurable. Chronic pain can hold its victims in a savage, demoralizing grasp.

But if you have chronic pain, there is good news. Today, new treatments, combined with a better understanding of how pain impulses originate and travel throughout your body, bring more hope than ever for conquering chronic pain.

How Pain Messages Travel Through Your Body

In the past decade, scientists have learned much about pain. In fact, the more researchers learn about the nature of pain, the more complex they find it to be. This greater knowledge about what causes pain and how pain messages travel through your body is important for developing more effective treatments to combat pain.

What exactly is pain? It is an individual, highly subjective perception. No two people interpret pain signals in the same manner. The International Association for the Study of Pain defined pain as “an unpleasant sensory as an “emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This statement emphasizes the emotional and psychological aspects of pain, in addition to its more widely recognized physical dimension.

How, then, does pain originate? And how are pain signals relayed to your brain for interpretation and response?

Acute pain and some forms of chronic pain originate with a noxious (unpleasant) stimulus to nerve endings embedded in your skin, joints, muscles or internal organs. Your body is supplied with a variety of nerve endings sensitive to touch, pressure, heat and cold.

In addition to these peripheral nerve endings, many nerve cells with extremely fine nerve fibers are activated only by intense, potentially harmful stimulation. Scientists call these nerve cells nociceptors, derived from the word noxious, which means physically harmful or destructive.

These nerve cells transmit pain stimuli through various nerve fibers called nociceptive (pain) pathways to a part of the spinal cord called the dorsal horn. Here, synapses send the signals on through the spinal cord in a manner analogous to electrical relay switches. These pathways, called spinothalamic tracts, then carry the pain impulses to the thalamus, the main relay center in your brain.

From here, the impulses are relayed to the cerebral cortex, the conscious area on the surface of the brain. Ultimately, the brain interprets the stimuli as pain and initiates action to halt it. For example, imagine that you've accidentally placed your hand on something hot. Your brain will “read” the pain impulses coming into your central nervous system from the injury site and initiate movement to stop the pain. In this instance, your brain sends a message to your muscles telling them to contract, and you pull back your hand.

Some peripheral nerve fibers that run to the spinal cord and brain transmit pain impulses faster than others. One such pathway acts as a sort of “express route” that reports facts instantaneously: where it hurts; how badly it hurts; and whether the pain is sharp or burning. Neuroscientists call these faster-transmitting pathways A-delta pain fibers. Slower-conducting pathways, which make connections with many nerve cells (neurons) en route, are known as C-pain fibers. In all instances, these impulses ultimately are relayed to the brain, where information about the location, intensity and nature of the pain is interpreted.

In addition to tissue injury, infection or inflammation can also activate these pain pathways. Nerve cells damaged by any of these causes release naturally occurring chemicals, called bradykinin, prostaglandin
and substance P. These chemicals enhance the sensitivity of nociceptors. This heightens your sensation of pain.

The impulses relayed through all these pathways together contribute to the emotional impact of
Pain – whether you feel frightened, anxious, angry or annoyed. Meanwhile, other branches of these
pain pathways alert another division of the nervous system, the autonomic nervous system. This system controls your body's vital functions such as breathing, blood flow, pulse rate, digestion and elimination. For example, pain can sound a general alarm in your autonomic nervous system, causing you to sweat,
and your pulse rate and blood pressure to increase.

Unfortunately, some chronic pain syndromes don't follow these “traditional” pain pathways. This is why treating chronic pain does not meet with unlimited success.

Pain: Acute vs. Chronic

The English language is replete with vivid descriptions of pain: throbbing, searing, numbing, sharp. In scientific terms, however, pain falls into two main categories:

Acute

This type of pain often results from disease or tissue damage. It starts suddenly, such as when you cut your hand or break a bone. Usually, you feel acute pain in the area where your body is damaged. This pain can last from a few seconds to several months, but subsides as normal healing occurs.

Physically, you may react to acute pain with an involuntary facial expression, such as a grimace, and “body language of sheltering or protecting the injured area. You also may perspire, breathe rapidly, turn pale and have changes in blood pressure.

Chronic

This form of pain lasts for more than three months, or beyond the time the condition would normally take to heal. Chronic pain may occur without a specific injury or disease; it ranges from mild to disabling.

You won't have involuntary responses such as rapid heart beat. Rather physical deterioration such as loss of muscle strength - is common. Several behavioral changes also can accompany chronic pain: decline in sexual function, social relationships and job performance. Depression or anxiety may worsen the condition.

The Four Stages of Pain

Researchers have proposed various models to help explain the complexities of pain. One model involves the following four stages:

1. Activation or nociception – The stimulation of nerve endings.

2. Pain – Your mind's perception of nerve impulses.

3. Suffering - Your emotional reaction to pain, such as alarm, anxiety, frustration or depression. Suffering varies from person to person based on such factors as your sense of self-esteem, memory of
past pain, job status - as well as family, social and cultural factors.

4. Pain behavior and psychological changes – chronic pain can lead to negative feelings and a lowered sense of self-worth, which can result in significant psychological changes. Some people who suffer from chronic pain cast themselves into what psychiatrists and psychologists call the “invalid role” or “sick role.” A person may assume this role to gain additional help from family or medical personnel, or to amid conflict or responsibility. Sometimes, family, friends or colleagues unknowingly reinforce this behavior.

Some people who experience chronic pain also engage in certain behaviors to win other benefits from their condition. Examples include trying to win sympathy or attention, and to amid difficult activities or day-to-day responsibilities.
Doctors refer to this as “pain behavior.” Many pain specialists recommend psychological or psychiatric counseling for pain behavior.

Common Forms of Chronic Pain

Here are the most common types of chronic pain:

Low back pain

More people - about 15 percent of the population - suffer from low back pain than from any other form of chronic pain. It is unusual to find a curable cause of chronic back pain for most people. Occasionally, special imaging techniques may reveal a ruptured disc or other source of pressure on the spinal cord or nerve roots. More frequently, osteoarthritis of the spine is the cause. Despite progress in understanding how pain occurs, many questions remain unanswered about the causes of most low back pain.

Cancer pain

Between 60 percent and 80 percent of cancer pain results from the pressure of a growing tumor, or the spreading of tumor cells into other organs. Radiation treatment or chemotherapy can also generate pain. These treatments can cause fluid accumulation and swelling, irritate or destroy healthy tissue and, in some instances, make nerve endings more sensitive to pain. Depression and anxiety, common psychiatric conditions in cancer victims, can worsen the pain.

The pain associated with cancer may be mild at first, but can increase as the illness progresses. Cancers that affect the bones, cervix, stomach, lungs and pancreas are usually the most painful. More than any other form of chronic pain, cancer pain often responds well to drug therapy. In addition, surgery to remove the cancerous tissue, and self-help groups may offer relief.

Headache pain

The most common form of headache is the so-called tension headache. However, doctors are not certain that this head pain is specifically linked to muscle tension. Often, stressful events and the onset or worsening of this type of headache are not directly related.

The throbbing pain characteristic of a migraine headache may be related to alterations in the blood vessels within your head. Genetics, medications, alcohol, certain foods, exertion, and anxiety or depression may provoke a migraine.

Arthritis pain

Arthritis is a general description for an affliction of the joints. Osteoarthritis is a form of arthritis of unknown cause. It typically affects joints in the knees, hands, hips, and backbone. Pain stems from use of the joint and is worse at the end of the day. Rheumatoid arthritis involves inflammation (swelling, congestion and thickening) of the soft tissue that surrounds the joint spaces typically in the areas of the hands and feet. Rheumatoid arthritis results from a disorder of the immune system. Psychological factors do not appear to play a major role in the development of rheumatoid arthritis.

Rheumatism

This syndrome of generalized aching in most parts of the body has occurred for generations. When the condition lasts for more than three months, it is commonly called fibromyalgia. The condition sometimes is associated with poor, non-restful sleep. Fibromyalgia is only disabling if you allow the
pain to rule your life.

An imbalance of neurochemicals, such as substance P, may be responsible for the pain of fibromyalgia. Treatment focuses on restoring good sleep, enhancing physical conditioning and providing reassurance that there are no crippling, deforming or life-threatening consequences of this pain.

Neuropathic pain

Damage to the peripheral or central nervous system can produce one of the most difficult forms of chronic pain for doctors to treat. Trigeminal neuralgia and postherpetic neuralgia are two common types of neuropathic pain.

People who have trigeminal neuralgia experience severe, stabbing pain that affects the cheek, lips, gums or chin on one side of the face. Even though the pain may last at most only a few minutes, it can be debilitating. Because the pain often provokes wincing, the condition is commonly called tic douloureux
or “painful twitch.” Postherpetic neuralgia is another type of burning, searing pain that follows an attack of herpes zoster (shingles). Ukeothertypes of chronic pain, tic douloureux and postherpetic neuralgia may be associated with emotional upset. Both conditions are more common among senior citizens.

Another severely painful neuropathic disorder is “phantom pain.” This is a puzzling condition that an estimated 5 percent to 10 percent of all amputees experience. Nerves in the stump of the limb may transmit electrochemical messages to the brain, where they are misread as originating in the missing limb.

Somatoform Pain

Somatoform pain refers to pain and changes in behavior that cannot be fully explained by physical disease or injury. The problems of the “sick role,” pain behavior and abuse of prescription drugs are frequently the most troublesome parts of this syndrome for the patient, family and health care professional.

Factors That Influence How You Perceive Pain

You don't experience chronic pain as only physical discomfort. Your perception of pain also is shaped by your own personality, and by the social and cultural environment in which you live.

Anxiety and depression - The longer you experience pain, the more irritable and depressed you can become. That, in turn, leads to more pain and anxiety.

Childhood experiences - Being deprived of normal nurturing as a child, while receiving undue attention when injured, may teach you to use pain to obtain the same kind of attention as an adult.

Relationships - some people use pain as a way to avoid other problems, such as the fear of intimacy.

Sense of control - High self-esteem and a feeling of being in control of your life may help you cope better with pain. On the other hand, a poor self-image can make pain the focus of your identity. This can magnify your sense of pain.

Medications That Treat Chronic Pain

Medications can play an important role in treatment of chronic pain. Here are medications your physician can choose from when trying to control your chronic pain:

Nonsteroidal anti-inflammatory drugs (NSAIDs) – This large group of medications brings about pain by inhibiting the production of hormones called prostaglandins in your nervous system. These hormones appear to assist nerve fibers that carry pain impulses to your brain. NSAIDs, which include such well-known pain medications as aspirin, ibuprofen and acetaminophen, are now available over-the-counter in smaller doses than the prescribed form. Recent evidence indicates that some of the known side effects of NSAIDs, such as a worsening of even minor degrees of kidney disease, can occur at these lower doses.

Opiates - Opiates are the most effective class of analgesic medications for people with pain from cancer, surgery, burns and kidney stones. Opiate drugs include morphine, methadone, codeine, hydromorphone (Dilaudid) and meperidine (Demerol). Morphine, which gets its name from Morpheus, the Greek god of dreams, is the opiate against which the potency of all others traditionally is measured. Opiates can cause drowsiness, nausea, constipation and mood changes. In addition, extended use of opiates can lead to tolerance - the body becomes accustomed to certain amounts of the drug and no longer responds as well to it Because of the inevitable addiction that accompanies chronic opiate use, their use in treating chronic pain should be extremely limited. An exception to this caveat is in the treatment of people who are terminally ill.

Antidepressants - These medications can bring relief to some people with chronic pain, even in the absence of depression. They may help by interfering with serotonin and other chemical transmitters of nerve impulses. For example, these medications may help some persons with peripheral nerve damage (such as in the discomfort of shingles or the “burning foot sensation of diabetes). Depression, even when mild in degree, often accompanies chronic pain. Treating this depression may play a role in bringing pain relief. Because antidepressants are not addicting, you can use them for longer periods. But they can have uncomfortable side effects such as fatigue and bladder-emptying problems.

Anticonvulsants - some medications that treat epilepsy provide relief from some forms of chronic pain.

Although chronic pain is not associated with epilepsy, the ability of these medications to stabilize electrical activity within the brain may be the reason they benefit some people with chronic pain.

The Safe Way to Use Over-the-counter Pain Medications

We endorse these recommendations from the Food and Drug Administration for the safe use of over-the-counter products:

Read the label. Follow all instructions, cautions and warnings. Never exceed the listed maximum dosage.

Unless a doctor recommends otherwise, adults should not take a pain reliever for more than 10 consecutive days; the limit for children and teenagers is five days. To treat a fever, all age groups should use medications no longer than three days.

Don't take aspirin during the last three months of pregnancy, unless your physician recommends it. Aspirin can cause bleeding in both the mother and child.

Reye's syndrome is a rare but potentially fatal condition. Children and young adults, ages two to 20, should not take aspirin for chicken pox, flu or flu-like symptoms.

If you're allergic to aspirin, you may need to avoid medications that contain aspirin-like ingredients such as carbaspirin calcium, choline salicylate, magnesium salicylate and sodium salicylate.

Non-medicinal Pain Control Techniques

Here are non-medicinal treatments that physicians, psychologists and other health care professionals use to control various forms of chronic pain.

Acupuncture

A growing body of information confirms that this ancient approach, popular in Asia, triggers pair-suppressing chemicals within your body. Needle placement at prescribed locations along nerve pathways can reduce the perception of pain.

Biofeedback

The principle of biofeedback, in short, is that by learning to monitor your body's responses, you can modify these responses and reduce the impact of pain. Biofeedback uses an electronic monitor to note physical responses, such as changes in skin temperature, muscle tension and heart rate, which are part of your body's response to pain.

For example, a sound or light may signal an increase in electrical activity in your muscles. Using these signals, you can learn to modify your body's response to pain. Biofeedback is especially helpful in coping with headaches, back pain and other forms of chronic pain, particularly when used with other pain control methods, such as distraction, re-interpreting pain and relaxation.

Exercise

If you have arthritis, exercise can increase the range of motion for specific areas (such as the arms, legs and neck). Exercises that tone both abdominal and back muscles may help relieve and prevent back pain.

Whirlpool/massage

Nerve blocks

An injection of a local anesthetic may play a dual role in the management of chronic pain. Doctors use this technique to localize or exclude a nociceptive stimulus as the cause of a pain problem. The temporary nature of the local anesthetic's effect can be beneficial in facilitating mobilization and rehabilitation for many people with chronic pain.

In many instances, doctors use a cortison-like preparation to prolong the effect. This is especially true in cases where inflammation is present. In patients with advanced cancer, doctors may inject a chemical that destroys the nerve. Permanent nerve blocks are less desirable for other types of chronic pain, however, because the remaining live nerve may begin to send its own pain messages in a few months.
Also, local anesthetics tend to affect more than the target area. (That's why your cheek and tongue feel numb after your dentist injects a local anesthetic.) Future research may help pinpoint which nerve fibers should receive the blockage.

TENS

This acronym stands for transcutaneous (or across the skin) electrical nerve stimulation. The use of electrical current as a means of “healing” dates back to the ancient Romans, who used electric eels and torpedo fish to treat pain. In recent years, doctors have revived the concept of using electrical current to treat pain.

In TENS therapy, electrodes are placed directly on your skin over the painful area, or at key points on the pain nerve pathway. A small battery-powered generator sends pulses of current to the electrodes. You can regulate the current by moving a magnet over the generator. The procedure has few side effects and also helps relieve mild, persistent pain, such as sore muscles, tennis elbow or postoperative discomfort.

Surgery

Often, nerve fibers that carry signals about tissue injury are packed together in small bundles called spinothalamic tracts in the spinal cord. Surgically cutting selected nerve bundles in the spinal cord may reduce the sensation of pain. However, pain often returns within a few weeks or months after this type of surgery.

Surgeons reserve this procedure, called a cordotomy, for people in whom all other pain control methods have failed. The operation is most successful for pain that originates on one side of your body. This form of treatment is reserved for terminally ill patients.

Communicating With Your Physician

If you experience chronic pain, work closely with your physician to determine the cause of the pain, if possible; and the most effective form of treatment. Here are some practical tips for talking with your physician:

Describe your symptoms completely. Tell your doctor what your pain is like. Is it sharp or dull? When are your symptoms most pronounced? Is your pain worse at night?

Recount any past injuries. Chronic pain sometimes is linked to an injury or disease that occurred many years before.

Follow your physician's instructions. No matter what type of treatment your physician decides to try first to manage your pain, follow his or her directions. Deviations from prescribed treatments can make them ineffective.

Be patient. The longer you suffer from chronic pain, the less likely it is that your physician will find a single, treatable disease as the cause. If, after a thorough search, your doctor cannot pinpoint the cause of your pain, don't construe such a report as an accusation by your doctor that you're a hypochondriac or are imagining your symptoms.

The word pain derives from poena, a Latin word meaning “punishment.” Historically, pain represented the concept of retribution by the gods.

Aristotle described pain as a “passion of the soul.” That definition remains apt, even as we learn more of how pain originates and travels through your body.

There may be no single, quick cure for your pain. But by using the concepts outlined in here, you and your doctor can work together to improve the way you perceive and respond to chronic pain.